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Old 12-31-2019, 11:54 AM
 
Location: in my mind
5,333 posts, read 8,558,285 times
Reputation: 11140

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Quote:
Originally Posted by organic_donna View Post
Did you read the requirements?

“Have no third party coverage for Vaccines OR be enrolled in a Medicare Part D Prescription Drug Plan and have spent at least $600 on prescription medicines through your Medicare Part D Prescription Drug Plan during this calendar year”.


I called Medicare and they don’t cover the shot, part D covers it, but it costs over $300.00, it was free with Obamacare.
So far I have checked two Wellcare formularies for 2020 and they both say that Shingrix is covered at the tier 3 level, which is $47.

Here is one that I checked, which is for their "Classic" plan https://fm.formularynavigator.com/FB...lary_20410.pdf

Which plan do you have with them? If you provide the name and state I will look up that formulary and see what it says.
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Old 12-31-2019, 02:02 PM
 
Location: OH>IL>CO>CT
7,528 posts, read 13,656,823 times
Reputation: 11926
Quote:
Originally Posted by KittenSparkles View Post
So far I have checked two Wellcare formularies for 2020 and they both say that Shingrix is covered at the tier 3 level, which is $47.

Here is one that I checked, which is for their "Classic" plan https://fm.formularynavigator.com/FB...lary_20410.pdf

Which plan do you have with them? If you provide the name and state I will look up that formulary and see what it says.
Doesn't Wellcare have a $435 deductible on all Tier 3 and above plans, and some Tier 1 & 2 ?

See Summary of Benefits at:
https://www.wellcare.com/Connecticut...llCare-Classic
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Old 12-31-2019, 04:02 PM
 
2,615 posts, read 2,303,799 times
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Quote:
Originally Posted by reed303 View Post
Doesn't Wellcare have a $435 deductible on all Tier 3 and above plans, and some Tier 1 & 2 ?

See Summary of Benefits at:
https://www.wellcare.com/Connecticut...llCare-Classic
Yes,
For the Shingrix vaccine you first have to meet the deductible.
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Old 12-31-2019, 04:06 PM
 
2,615 posts, read 2,303,799 times
Reputation: 4477
Quote:
Originally Posted by KittenSparkles View Post
So far I have checked two Wellcare formularies for 2020 and they both say that Shingrix is covered at the tier 3 level, which is $47.

Here is one that I checked, which is for their "Classic" plan https://fm.formularynavigator.com/FB...lary_20410.pdf

Which plan do you have with them? If you provide the name and state I will look up that formulary and see what it says.
I have WellCare Value Script (PDP) in North Carolina. CVS told me the shot was $170 each with WellCare.

Last edited by organic_donna; 12-31-2019 at 04:44 PM..
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Old 01-13-2020, 10:41 PM
 
Location: Gulf Coast
1,458 posts, read 1,172,577 times
Reputation: 3098
I get all the lab tests done twice a year. I asked my dr. last time I was there why I was coming twice a year and why I was getting lab tests that often and she said it was because I am on cholesterol medicine and a couple other ones. Apparently that changes the rules of why the labs are covered. I was also told the wellness visit is only a BP and temp and O2 check and the doctor goes over lab results. If the patient starts talking about anything more and there is more of a physical exam performed it won't be covered by medicare and becomes a regular medical physical which may or may not be covered at that frequency.


I am lucky I used to have a dr. who would talk and discuss things with me regardless of which visit I was there for..and order a pres. if I needed something different... but she's moved away and I am now starting over.


Our medicare (regular + a supplement policy) has been a way better experience than we had under private insurance. If you had a really really good policy paid for by a big company, your experience might be different, but basically we've had to pay just about nothing except for a test or two which was ordered before the year was out (one psa test and they almost did a mamogram before the year was out which wasn't covered either). I would hate to go back to the old insurance we had.
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Old 01-17-2020, 05:00 PM
 
555 posts, read 596,534 times
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Oh my, this is all clear as mud.

I qualified for Medicare in August and set up a "Welcome to Medicare" visit. The nurse practitioner that I chose (there is a shortage of PCP's that take Medicare here in the Prescott, AZ area) reviewed my records, took my vitals, listened to my lungs and heart - and told me that she heard a heart murmur (absolutely NO history, and I had a complete physical by my PCP in CO in April) so she sent me for an echocardiogram... which showed nothing. So far I have only been billed for $72; I have Medicare with Plan G AARP supplement. I keep thinking there'll be another bill; who knows??

What I'm more confused about is when to schedule my next visit. I will need a med refill in April; I'll also need a dexascan (hx of osteoporosis and it's due) and mammogram. But do I have to wait a year from my "Welcome to Medicare" visit to have a wellness visit?? I guess I'll message my NP and ask her to extend my prescription (synthroid, and technically will need blood work for THAT; sheesh) 'til August.

I worked for a hospital in Colorado. My insurance coverage, particularly for preventative stuff, was awesome. I am so not thrilled with the confusion of Medicare.
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Old 01-17-2020, 05:19 PM
 
2,759 posts, read 2,056,410 times
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Does anyone know whether the cholesterol test that is paid for under the "paid for once every 5 years" group (described as "tests for cholesterol, lipid, and triglyceride levels") is the less-expensive/less detailed test, or the better/gold-standard VAP test that shows the LDL Pattern (A, B, or A/B) that you have? The other test does not do that.

Because the less expensive test is, IMHO, useless. Okay, well, it's better than no test at all but it doesn't give the same level of information as the VAP test does.

I am assuming that "once every 5 years" is counted only from the point at which one has first enrolled in Medicare Part B? Not that it really matters in my case because the last time I had the VAP test was 2008, lol
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Old 01-17-2020, 07:31 PM
 
Location: Wisconsin
25,574 posts, read 56,533,893 times
Reputation: 23394
Quote:
Originally Posted by bigdogmom13 View Post
What I'm more confused about is when to schedule my next visit. I will need a med refill in April; I'll also need a dexascan (hx of osteoporosis and it's due) and mammogram.

But do I have to wait a year from my "Welcome to Medicare" visit to have a wellness visit?? I guess I'll message my NP and ask her to extend my prescription (synthroid, and technically will need blood work for THAT; sheesh) 'til August.
You must wait another year before scheduling Wellness:
Quote:
If you've had a “Welcome to Medicare” visit within the last 12 months, you must wait 12 months after your Welcome visit to schedule your Annual Wellness Visit.

https://cahealthadvocates.org/unders...d-questions-2/
Schedule visit(s) for followup care outside of Wellness. Provider should bill it as a normal office visit to which Medicare will assign a reimbursement. After your deductible of $198, Medicare and supplement should pay all of it. If you need several visits because of various issues, Medicare should cover it. Welcome and Wellness are too tricky to navigate for followup care, imo.

Fwiw, I recently had lab work done at an urgent care center. Medicare insurer was billed $446. Per Medicare's reimbursement schedule using 2017 codes - lab will get about $58 - not $446. The actual visit and procedure - totaling one hour - performed by the NP was billed at $846, provider will get $202. In total, provider will be paid about 20% of the $1,292 billed.

Last edited by Ariadne22; 01-17-2020 at 07:44 PM..
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Old 01-17-2020, 07:42 PM
 
Location: Wisconsin
25,574 posts, read 56,533,893 times
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Quote:
Originally Posted by BBCjunkie View Post
Does anyone know whether the cholesterol test that is paid for under the "paid for once every 5 years" group (described as "tests for cholesterol, lipid, and triglyceride levels") is the less-expensive/less detailed test, or the better/gold-standard VAP test that shows the LDL Pattern (A, B, or A/B) that you have? The other test does not do that.

Because the less expensive test is, IMHO, useless. Okay, well, it's better than no test at all but it doesn't give the same level of information as the VAP test does.
If you know the code for that procedure, see if it is listed on Medicare's schedule, here:

https://cgsmedicare.com/partb/pubs/m...artb_02-17.pdf

Then ask doc if he thinks it is necessary and will Medicare cover it.
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Old 01-19-2020, 09:01 AM
 
2,759 posts, read 2,056,410 times
Reputation: 5005
Quote:
Originally Posted by Ariadne22 View Post
If you know the code for that procedure, see if it is listed on Medicare's schedule, here:

https://cgsmedicare.com/partb/pubs/m...artb_02-17.pdf

I found a link that gives two CPT codes for the VAP test: 83701 and 84478. 83701 is listed with a price of $34.05 next to it. 84478 is also listed but with a notation of QW and also $7.88 in the price column.

Does it matter that your linked PDF says "Kentucky Only" and "Kentucky and Ohio Part B" ? I am not in either of those states.
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